Healthcare Provider Details

I. General information

NPI: 1558156307
Provider Name (Legal Business Name): LUCKY MILO WHITBURN-THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 UNIVERSITY AVE
BERKELEY CA
94703-1422
US

IV. Provider business mailing address

1521 UNIVERSITY AVE
BERKELEY CA
94703-1422
US

V. Phone/Fax

Practice location:
  • Phone: 510-644-6965
  • Fax:
Mailing address:
  • Phone: 510-981-5290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number390200000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: